The colonic motility and classification of patients with slow transit constipation by high-resolution colonic manometry

BackgroundThis study aimed to evaluate the colonic motility of slow transit constipation (STC) patients using high-resolution colonic manometry (HRCM) and classify the patients’ subtypes to instruct treatment based on HRCM characteristics.MethodsThis study enrolled one hundred and twenty-six STC patients and 35 volunteers (healthy controls, HCs). Ambulatory HRCM was performed in all participants by placing a 36-sensor water-perfused probe up to the cecum. Quantitative and qualitative manometric analysis was conducted in the state of rest, postprandial, during sleep, and wakefulness.ResultsThe occurrence rate and times of high amplitude propagated contraction (HAPC) in STC patients were lower than HCs. As for the HAPC contraction characteristics, the mean velocity was similar, contraction length, amplitude, area under the curve (AUC) of pressure wave, and duration were reduced in STC patients compared with HCs. In addition, the occurrence rate and times of low amplitude propagated contraction (LAPC) in STC patients were similar compared to HCs. There was no difference in HAPC occurrence, LAPC occurrence, and most detailed HAPC characteristics between STC patients ≤60 years and STC patients >60 years or between male STC patients and female STC patients. Based on the HRCM characteristics (including HAPC, neostigmine induced HAPC, LAPC, and waking/gastrocolic response), STC patients were classified into four types, respectively, with recommended treatment by clinical experience.ConclusionHRCM serves as a valuable tool in characterizing, classifying the pathophysiology, and guiding clinical management for STC.     

Normal aspects of colorectal motility and abnormalities in slow transit constipation

Human colonic motility is a relatively difficult topic to investigate. However, the refinement of manometric techniques in recent years enabled us to study both the proximal and distal segments of the viscus. The present paper reviews our knowledge about normal aspects of colorectal motility in man and the abnormalities found in slow transit constipation (STC), one of the most frequent and difficult to treat subtypes of constipation. An internetbased search strategy of the Medline and Science Citation Index was performed using the keywords colon, colonic, colorectal, constipation, slow transit, motility, rectal, rectum in various combinations with the Boolean operators AND, OR and NOT. Only articles related to human studies were used, and manual cross-referencing was also performed. Most of colonic motor activity is represented by single nonpropagated contractions, rarely organized in bursts; this activity is maximal during the day, especially after waking and following meals. In addition, a specialized propagated activity with propulsive features is detectable, represented by high-and low-amplitude propagated contractions. In the severe form of constipation represented by the slow transit type, the above motor activity is completely deranged. In fact, both basal segmental activity (especially in response to meals) and propagated activity (especially that of high amplitude) are usually decreased, and this may represent a physiologic marker of this disorder. Human colonic motor activity is quite a complex issue, still only partly understood and investigated, due to anatomic and physiological difficulties. In recent years, however, some more data have been obtained, even in proximal segments. These data have helped in elucidating, although only in part, some pathophysiological mechanisms of chronic constipation, and especially of the STC subtype.     

慢传输型便秘外科治疗的主要术式及疗效

近年来,便秘的发病率呈缓慢上升趋势。然而,国际上对于慢传输型便秘的发病原因及发病机理尚未完全认清。虽然经过一段时间的内科保守治疗能够暂时缓解便秘症状,但不能从根本上解决慢传输型便秘的问题。手术可能是最终而有效的治疗慢传输型便秘的方法。现阶段,治疗慢传输型便秘的主要术式有：全结肠切除回直肠吻合术、结肠次全切除盲肠直肠吻合术、结肠旷置术和末端回肠造口术等。本文主要介绍这几种术式及其疗效。     

Hyperglycemia modulates gallbladder motility and small intestinal transit time in man

The aim of the present study was to investigate the effect of acute hyperglycemia on (1) the intestinal phase of gallbladder contraction induced by the intraduodenal administration of emulsified fat, and (2) the small intestinal transit time measured by the lactulose breath hydrogen test. Six healthy volunteers were studied in random order during normoglycemia and hyperglycemia (blood glucose levels 15 mmol/liter). Gallbladder volumes were measured with ultrasonography. Administration of 1 and 2 g/hr of fat resulted in significant reductions in gallbladder volumes from 24±2 cm³ to 11±1 cm³ (P<0.05) and 8±1 cm³ (P<0.05), respectively during normoglycemia, and from 24±2 cm³ to 21±2 cm³ (P<0.05) and 16±2 cm³, respectively (P<0.05) during hyperglycemia. Compared to normoglycemia, the gallbladder contraction was significantly (P<0.05) reduced during hyperglycemia. No significant differences in CCK secretion were observed between experiments. Small intestinal transit time during hyperglycemia (101±12 min) was significantly (P<0.05) prolonged compared to normoglycemia (57±12 min). During hyperglycemia, basal PP levels and PP secretion in response to intraduodenal fat were significantly (P<0.05) reduced compared to normoglycemia. It is concluded that (1) low doses of intraduodenal emulsified fat result in significant gallbladder contraction and CCK secretion, (2) acute hyperglycemia inhibits intraduodenal fat induced gallbladder contraction, (3) acute hyperglycemia does not affect the intraduodenal fat induced CCK secretion, (4) small intestinal transit is significantly prolonged during acute hyperglycemia, and (5) acute hyperglycemia inhibits basal and stimulated plasma PP secretion, suggesting impaired vagal-cholinergic tone during hyperglycemia.     

Involvement of apolipoprotein A-IV and cholecystokinin1 receptors in exogenous peptide YY3 36-induced stimulation of intestinal feedback

Peptide YY (PYY)(3-36), released by intestinal lipid elicits functional effects that comprise the intestinal feedback response to luminal nutrients, but the pathway of action is not fully characterized. The aim of the present study was to determine the role of the apolipoprotein (apo) A-IV-cholecystokinin (CCK)(1) receptor (CCK(1)R) pathway in exogenous PYY(3-36)-induced activation of the gut-brain axis and inhibition of gastric emptying and food intake. PYY(3-36) (5 microg/100 g ip) significantly inhibited gastric emptying of a chow meal in wild-type but not A-IV(-/-) mice andCCK(1)R receptor blockade with devazepide (10 microg/100 g), abolished PYY(3-36)-induced inhibition of gastric emptying. PYY(3-36)-induced inhibition of food intake in both ad libitum-fed and 16-h fasted mice was unaltered in A-IV(-/-) mice, compared with wild-type controls, or by CCK(1)R receptor blockade with devazepide. PYY(3-36) activated neurons in the midregion of the nucleus of the solitary tract (bregma -7.32 to -7.76 mm) in A-IV(+/+) mice; this was measured by immunohistochemical localization of Fos protein. PYY(3-36)-induced Fos expression was significantly reduced by 65% in A-IV(+/+) mice pretreated systemically with the sensory neurotoxin capsaicin (5 mg/100 g), 78% by the CCK(1)R antagonist, devazepide (10 microg/100 g), and 39% by the Y2R antagonist, BIIE0246 (200 and 600 microg/100 g) and decreased by 67% in apo A-IV(-/-) mice, compared with A-IV(+/+) controls. The data suggest a role for apo A-IV and the CCK(1)R in PYY(3-36)-induced activation of the vagal afferent pathway and inhibition of gastric emptying, but this is likely not the pathway mediating the effects of PYY(3-36) on food intake.     

Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation

BACKGROUND & AIMS: Biofeedback is reported to be as effective for slow transit constipation as for pelvic floor dyssynergia and no more effective than education. We aimed to test the hypothesis that biofeedback benefits only patients with pelvic floor dyssynergia, describe the physiologic mechanism of treatment, and identify predictors of success. METHODS: Fifty-two patients (49 women; average age, 35 years), all with delayed whole gut transit, included 34 with pelvic floor dyssynergia, 12 with slow transit only, and 6 who met only 1 of 2 criteria for pelvic floor dyssynergia. All received 5 weekly biofeedback sessions directed at increasing rectal pressure and relaxing pelvic floor muscles during straining plus practice defecating a balloon. Patients were retested by questionnaire; symptom diary; balloon defecation; transit study at 1, 6, 12, and 24 months; and anorectal manometry at 1 and 6 months. RESULTS: At 6 months, greater improvements were seen in pelvic floor dyssynergia compared with slow transit only; 71% versus 8% reported satisfaction ( P = .001), and 76% versus 8% reported >/=3 bowel movements per week ( P < .001). Improvements were maintained at 24 months of follow-up. Biofeedback eliminated dyssynergia in 91% and enabled 85% to defecate the balloon. Satisfaction was correlated with improved ability to defecate the balloon (rho = .73; P < .001), reductions in dyssynergia (rho = .69; P < .001), and increased rectal pressure during straining (rho = .36; P < .01). Success was predicted by pelvic floor dyssynergia, milder constipation, and less frequent abdominal pain at baseline. CONCLUSIONS: Biofeedback is an effective treatment for pelvic floor dyssynergia but not slow transit constipation.     

慢传输型便秘结肠肌间神经丛超微结构改变

目的　慢传输型便秘（ＳＴＣ） 病因不清、症状顽固、临床处理较困难． 进一步探讨其发生和发展的病理学基础．方法　应用电镜技术对１４ 例ＳＴＣ 患者和１１ 例非梗阻性直肠癌患者经手术切除的乙状结肠标本进行了对照研究．结果　与对照组相比，ＳＴＣ 患者结肠肌间神经丛的超微病理改变表现为：神经元及其突起有十分明显的退行性变，轴突及树突空化呈网格状结构，胞质内出现空泡及脂褐素等；轴突末端膨体及突触前区内突触小泡含量明显减少，大部分突触小泡出现空化．结论　ＳＴＣ 患者结肠肌间神经丛有明显的神经病理学改变，存在递质耗竭或递质合成、传输障碍等现象，它是ＳＴＣ 患者肠道传输减慢的超微病理基础． 这种改变可能与ＳＴＣ 患者长期滥用接触性泻剂有关．     

Colectomy for slow transit constipation: effective for patients with coexistent obstructed defecation

Background

Patient selection is a crucial step when considering total abdominal colectomy and ileorectal anastomosis (TAC/IRA) for refractory constipation.

Purpose

This study aimed to evaluate the results of short- and long-term outcomes for patients with pure slow transit constipation (STC) compared to those with slow transit and features of obstructive defecation (STC + OD).

Methods

This study included all patients who underwent TAC/IRA for constipation from 1999–2010. Patients were divided into two groups: group A (STC) and group B (STC + OD) based on abnormal physiology or motility testing in addition to the surgeon's clinical impression of symptomatic obstructive defecation. Demographics, operative variables, and short-term outcomes were collected by retrospective chart review and were compared between groups. Long-term functional outcomes were assessed by telephone survey. This included: number of bowel movements, use of laxatives, antidiarrheal medications, and surgery satisfaction. Validated questionnaires were collected postoperatively.

Results

One hundred forty-four patients (143 females; mean age, 40 (18–68) years old) underwent TAC/IRA by either laparoscopic (63 (44 %)) or open (81 (56 %)) techniques. One hundred three patients had pure STC and 41 had STC + OD. Four patients underwent TAC with end ileostomy at first procedure. Seven patients underwent surgery after a trial of diverting ileostomy. One patient died unexpectedly, 2 days after uneventful surgery. Median follow-up was 43 (IQR, 16–75) months. Five (5 %) patients in group A and two (5 %) in group B underwent subsequent ileostomy for poor functional outcomes. Eighty-eight (68 %) patients were available by telephone. Short- and long-term outcomes were equivalent in both groups as well as patient satisfaction (89 vs. 85 %, p?=?0.7).

Conclusions

Total abdominal colectomy can be offered to selective patients with slow transit constipation and obstructive defecation with equivalent long-term results.     

温针灸对慢传输型便秘大鼠结肠P物质、血管活性肠肽表达的影响

目的 探讨温针灸对慢传输型便秘(STC)大鼠肠道传输功能及结肠P物质(SP)、血管活性肠肽(VIP)阳性表达的影响.方法 选用SD大鼠100只,随机取10只为正常组,其余90只造成STC大鼠模型,并随机分为模型组、针刺组和温针组.分别测定大鼠肠道传输功能及结肠SP、VIP阳性表达面积.结果 针刺组、温针组可明显缩短大鼠首粒黑便排出时间(P＜0.01),且温针灸效果优于针刺组(P＜0.05).STC大鼠结肠SP、VIP阳性表达较正常组明显降低(P＜0.01);针刺和温针灸均能明显提高结肠SP、VIP阳性表达面积(P＜0.01);且温针灸在提高结肠SP阳性表达面积上效果优于单纯针刺(P＜0.01).结论 针灸治疗STC有效,其机制与提高结肠SP、VIP阳性表达有关;温针灸效果更好.     

Regulation of the peptidergic nerves (substance P and vasoactive intestinal peptide) in the colon of women patients with slow transit constipation: an in vitro study

BACKGROUND/AIMS: In histological studies, there is evidence to suggest a diminution of the peptidergic nerves such as vasoactive intestinal peptide (VIP) and substance P (SP) in the enteric nervous system in the colon of patients with slow transit constipation (STC). To clarify the pathophysiological significance of peptidergic nerves in the colon of patients with STC, we investigated the enteric nerve responses on pathological and normal bowel segments derived from patients with STC and patients who underwent colon resection for colon cancers, respectively. METHODOLOGY: Twenty-eight preparations were taken from the pathological sigmoid colon of 16 women with STC (aged 40-58 years, average 48.8 years). Forty-eight preparations were taken from the normal sigmoid colon of 20 women with colonic cancer (aged 40-55 years, average 49.6 years). A mechanographic technique was used to evaluate in vitro muscle responses to VIP and SP of adrenergic and cholinergic nerves before and after treatment with various autonomic nerve blockers. RESULTS: Responses mediated by non-adrenergic non-cholinergic (NANC) inhibitory nerves were found in the normal colon, but were more frequently in the colon with STC than in the normal colon (p < 0.01). Responses mediated by excitatory nerves such as cholinergic nerves were more dominant in the normal colon than in the STC colon. At 1 x 10(-8), 1 x 10(-7), 1 x 10(-6) g/mL, VIP and SP in both the normal and STC colonic muscle strips produced a concentration-dependent relaxation to VIP and contraction to SP. In addition, the relaxation reaction to VIP in the colon with STC was also weaker than in the normal colon (p < 0.01). The contraction reaction to SP in the colon with STC was weaker than in the normal colon (p < 0.01). VIP acts through neural mechanisms, whereas SP may act both through nerves and also directly on both the normal and STC muscle strips. CONCLUSIONS: Responses mediated by NANC inhibitory nerves were significantly increased in the colon with STC compared with the normal colon. A decrease of responses to peptidergic nerves such as SP and VIP may also play an important role in the impaired motility observed in the colon of patients with STC. These results indicate that the disturbances in the neural component of the enteric nervous system in the colon of women patients with STC may initiate or contribute to the functional changes.     

Gallbladder motor function, plasma cholecystokinin and cholecystokinin receptor of gallbladder in cholesterol stone patients

AIM: To study the interactive relationship of gallbladder motor function, plasma cholecystokinin (CCK) and cholecystokinin A receptor (CCK-R) of gallbladder in patients with cholesterol stone disease. METHODS: Gallbladder motility was studied by ultrasonography in 33 patients with gallbladder stone and 10 health subjects as controls. Plasma CCK concentration was measured by radioimmunoassay in fasting status (CCK-f) and in 30 min after lipid test meal (CCK-30). Radioligand method was employed to analyze the amount and activity of CCK-R from 33 gallstone patients having cholecystectomy and 8 persons without gallstone died of severe trauma as controls. RESULTS: The percentage of cholesterol in the gallstone composition was more than 70%. The cholesterol stone type was indicated for the patients with gallbladder stone in this study. Based on the criterion of gallbladder residual fraction of the control group, 33 gallstone patients were divided into two subgroups, contractor group (14 cases) and non-contractor group (19 cases). The concentration of CCK-30 was significantly higher in non-contractor group than that in both contractor group and control group (55.86±3.86 pmol/L vs 37.85±0.88 pmol/L and 37.95±0.74 pmol/L, P<0.01), but there was no difference between contractor group and control group. Meanwhile no significant difference of the concentration of CCK-f could be observed among three groups. The amount of CCK-R was lower in non-contractor group than those in both control group and contractor group (10.27±0.94 fmol/mg vs 24.59±2.39 fmol/mg and 22.66±0.55 fmol/mg, P<0.01). The activity of CCK-R shown as KD in non-contractor group decreased compared to that in control group and contractor group. Only was the activity of CCK-R lower in contractor group than that in control group. The ejection fraction correlated closely with the amount of CCK-R (r=0.9683, P<0.01), and the concentration of CCK-30 correlated negatively with the amount of CCK-R closely (r=-0.9627, P<0.01). CONCLUSION: The distinctive interactive relationship of gallbladder emptying, plasma CCK and CCK-R in gallbladder from this study suggested that the defect of CCK-R may be a key point leading to the impairment of gallbladder motor function and the pathogenesis of cholesterol gallstone formation may differ in two subgroups of gallstone patient, gallbladder non-contractor group or contractor group.     

Pan-colonic decrease in interstitial cells of Cajal in patients with slow transit constipation

BACKGROUND: Interstitial cells of Cajal (ICC) are required for normal intestinal motility. ICC are found throughout the human colon and are decreased in the sigmoid colon of patients with slow transit constipation. AIMS: The aims of this study were to determine the normal distribution of ICC within the human colon and to determine if ICC are decreased throughout the colon in slow transit constipation. PATIENTS: The caecum, ascending, transverse, and sigmoid colons from six patients with slow transit constipation and colonic tissue from patients with resected colon cancer were used for this study. METHODS: ICC cells were identified with a polyclonal antibody to c-Kit, serial 0.5 microm sections were obtained by confocal microscopy, and three dimensional software was employed to reconstruct the entire thickness of the colonic muscularis propria and submucosa. RESULTS: ICC were located within both the longitudinal and circular muscle layers. Two networks of ICC were identified, one in the myenteric plexus region and another, less defined network, in the submucosal border. Caecum, ascending colon, transverse colon, and sigmoid colon displayed similar ICC volumes. ICC volume was significantly lower in the slow transit constipation patients across all colonic regions. CONCLUSIONS: The data suggest that ICC distribution is relatively uniform throughout the human colon and that decreased ICC volume is pan-colonic in idiopathic slow transit constipation.     

Interaction of peptide YY with rat intestinal epithelial plasma membranes: binding of the radioiodinated peptide

High affinity binding sites for peptide YY (PYY) have been identified and characterized in plasma membranes prepared from rat jejunal epithelium by studying the kinetics, stoichiometry, and chemical specificity of the interaction of 125I-labeled PYY with membranes. Binding of [125I]PYY was rapid, saturable, reversible, specific, and depended on temperature, pH, and ionic strength. In optimized steady state conditions of binding (2 h of incubation at 15 C), the degradation of both [125I] PYY and binding sites did not exceed 20%. The concentration dependence of PYY binding, determined by adding increasing concentrations of [125I]PYY, indicated that specific binding saturated at 2-3 nM peptide. Scatchard analysis revealed a single class of binding sites with a dissociation constant (Kd) of 434 +/- (SE) 56 pM and a binding capacity of 336 +/- 41 fmol/mg protein (n = 11). Identical results were obtained when increasing concentrations of unlabeled PYY were added to a fixed concentration of [125I]PYY, indicating that the radioiodinated peptide has the same apparent affinity as native PYY. Peptides structurally unrelated to PYY, such as members of the vasoactive intestinal peptide family, insulin, or cholecystokinin octapeptide, were unable to compete with [125I]PYY for binding to membranes. Rat, human, and avian pancreatic polypeptides, which display, respectively, 42%, 47%, and 53% homology with PYY, did inhibit [125I]PYY binding but with an approximate or equal to 100,000-fold lower potency than PYY, indicating the strict structural requirement for recognition by PYY binding sites. In contrast, natural or synthetic neuropeptide Y, which has 25 out of 36 amino acids in common with PYY, retained a high affinity for PYY binding sites [only 4.7 +/- 1.2 (n = 5) times lower than that of PYY]. Specific [125I]PYY binding was particularly high in the upper small intestine and could not be detected in stomach, large intestine, or liver. These findings indicate that rat small intestinal epithelium expresses specific binding sites for the candidate gut hormone PYY that also binds the neuropeptide Y with high affinity, suggesting that the two peptides may regulate the function of small intestinal epithelium, through interaction with a common receptor site.     

The effects of neurotensin in the colon of patients with slow transit constipation

BACKGROUND/AIMS: The cause of dysmotility in the colon of patients with slow transit constipation (STC) is still unknown. Neurotensin (NT) has recently been shown to be a neurotransmitter in the non-adrenergic non-cholinergic (NANC) excitatory nerves of the human alimentary tract. To clarify the physiological significance of NT in the colon of patients with STC, we examined the enteric nerve responses in lesional and normal bowel segments derived from patients with STC and patients who underwent colon resection for colonic cancers. METHODOLOGY: Twenty-eight preparations were taken from colonic lesions in 10 patients with slow transit constipation (2 men and 8 women, aged 23 to 70 years, mean 46.3 years). Forty-six preparations were taken from the normal colons of 16 patients with colonic cancer (8 men and 8 women, aged 40 to 66 years, mean 50.1 years). A mechanographic technique was used to evaluate in vitro muscle responses to electrical field stimulation (EFS) before and after treatment with various autonomic nerve blockers and NT. RESULTS: After blocking both the adrenergic and cholinergic nerves (Experiment 1), NT showed contraction reaction on both normal and STC colons in a concentration-dependent manner. The contraction reactions to NT in the normal colon were more dominant than those in the STC colon. There were significant differences between the frequency of contraction reactions to NT in normal colon strips and those in STC colon strips (P < 0.001). Following addition of tetrodotoxin (Experiment II), all muscle strips of normal and STC colons demonstrated contraction responses by NT. The effects of NT in the normal and STC colon muscle strips were essentially the same as in experiment 1, although the extent of contraction was somewhat diminished. CONCLUSIONS: Those results suggested that NT acts both via NANC excitatory nerves and also directly on the colonic smooth muscle. A decrease of NT mediates NANC excitatory nerves and plays an important role in the dysmotility observed in the colons of patients with STC.     

Effect of predigested fat on intestinal stimulation of plasma cholecystokinin and gall bladder motility in coeliac disease.

Cholecystokinin (CCK) release and gall bladder emptying in response to a fatty meal are completely abolished in coeliac disease. To determine the effect of lipid digestion on CCK release and gall bladder motility, six patients with untreated coeliac disease and a flat jejunal mucosa were studied on two separate days. After an overnight fast, the plasma CCK concentration and gall bladder volume were measured before and at regular intervals after the intraduodenal instillation of 60 ml corn oil (triglycerides) incubated with 40 ml saline or with 40 ml bile and pancreatic juice. The mean (SEM) concentration of free fatty acids in the aqueous phase of corn oil after incubation with bile and pancreatic juice (predigested corn oil) was 78 (35) mM compared with 0.1 (0.1) mM in the aqueous phase of corn oil incubated with saline (undigested corn oil). Integrated plasma CCK in response to predigested corn oil was significantly greater than that in response to undigested corn oil (101 (18) pM. 80 min v-2 (9) pM.80 min; p < 0.005). Similarly, integrated gall bladder contraction in response to predigested corn oil was significantly larger than that after undigested corn oil (817 (210) ml. 80 min v-225 (243) ml. 80 min; p < 0.05). In contrast to undigested corn oil, corn oil that has been predigested with bile and pancreatic juice induces plasma CCK secretion and gall bladder contraction in patients with untreated coeliac disease, presumably by generating and rendering soluble lipolytic products.     

Biofeedback provides long term benefit for patients with intractable, slow and normal transit constipation

Background—Many patients with idiopathicconstipation do not respond to conventional medical treatments.Recently biofeedback has been proposed as an alternative treatment butthe long term results, and which patients benefit, are unknown.Treatment has usually been restricted to patients with normal colonictransit and impaired pelvic floor coordination on straining.
Aims—To determine the efficacy and long termoutcome of biofeedback treatment in idiopathic constipation.
Methods—One hundred consecutive contactablepatients who had completed a course of biofeedback more than 12 monthspreviously were identified. Pretreatment details of bowel function andsymptoms, whole gut transit time, and anorectal physiological testing,which had been previously prospectively collected, were collated.Follow up consisted of structured interview. Sixty five per cent had slow transit and 59% had paradoxical pelvic floor contraction on straining.
Results—Median follow up was 23 months (range12-44). On long term follow up 55% felt that biofeedback had helpedand 57% felt their constipation was improved. There was a significant reduction in need to strain, abdominal pain, bloating, and oral laxative use. Spontaneous bowel frequency was significantly improved bytreatment. Patients with slow and normal transit, males and females,and those with and without paradoxical contraction of the analsphincter on straining, benefited equally from treatment. Anorectaltesting did not predict outcome.
Conclusion—This study suggests that biofeedbackis an effective long term treatment for the majority of patients withidiopathic constipation unresponsive to traditional treatments. Pelvicfloor abnormalities and transit time should not form selection criteria for treatment.

Keywords:constipation; biofeedback; follow up; laxatives; transit time